Costs of Fatal and Nonfatal Firearm Injuries in the U.S., 2019 and 2020.

INTRODUCTION: Firearm-related injuries are among the five leading causes of death for people aged 1-44 years in the U.S. The immediate and long-term harms of firearm injuries pose an economic burden on society. Fatal and nonfatal firearm injury costs in the U.S. were estimated providing up-to-date economic burden estimates. METHODS: Counts of nonfatal firearm injuries were obtained from the 2019-2020 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample. Data on nonfatal injury intent were obtained from the National Electronic Injury Surveillance System - Firearm Injury Surveillance System. Counts of deaths (firearm as underlying cause) were obtained from the 2019-2020 multiple cause-of-death mortality data from the National Vital Statistics System. Analyses were conducted in 2023. RESULTS: The total cost of firearm related injuries and deaths in the U.S. for 2020 was $493.2 billion, a 16 percent increase compared with 2019. There are significant disparities in the cost of firearm deaths in 2019-2020, with non-Hispanic Black people, males, and young and middle-aged groups being the most affected. CONCLUSIONS: Most of the nonfatal firearm injury-related costs are attributed to hospitalization. These findings highlight the racial/ethnic differences in fatal firearm injuries and the disproportionate cost burden to urban areas. Addressing this important public health problem can help ameliorate the costs to our society from the rising rates of firearm injuries.

Prevalence of Adverse Childhood Experiences Among U.S. Adults - Behavioral Risk Factor Surveillance System, 2011-2020.

Adverse childhood experiences (ACEs) are defined as preventable, potentially traumatic events that occur among persons aged <18 years and are associated with numerous negative outcomes; data from 25 states indicate that ACEs are common among U.S. adults (1). Disparities in ACEs are often attributable to social and economic environments in which some families live (2,3). Understanding the prevalence of ACEs, stratified by sociodemographic characteristics, is essential to addressing and preventing ACEs and eliminating disparities, but population-level ACEs data collection has been sporadic (1). Using 2011-2020 Behavioral Risk Factor Surveillance System (BRFSS) data, CDC provides estimates of ACEs prevalence among U.S. adults in all 50 states and the District of Columbia, and by key sociodemographic characteristics. Overall, 63.9% of U.S. adults reported at least one ACE; 17.3% reported four or more ACEs. Experiencing four or more ACEs was most common among females (19.2%), adults aged 25-34 years (25.2%), non-Hispanic American Indian or Alaska Native (AI/AN) adults (32.4%), non-Hispanic multiracial adults (31.5%), adults with less than a high school education (20.5%), and those who were unemployed (25.8%) or unable to work (28.8%). Prevalence of experiencing four or more ACEs varied substantially across jurisdictions, from 11.9% (New Jersey) to 22.7% (Oregon). Patterns in prevalence of individual and total number of ACEs varied by jurisdiction and sociodemographic characteristics, reinforcing the importance of jurisdiction and local collection of ACEs data to guide targeted prevention and decrease inequities. CDC has released prevention resources, including Preventing Adverse Childhood Experiences: Leveraging the Best Available Evidence, to help provide jurisdictions and communities with the best available strategies to prevent violence and other ACEs, including guidance on how to implement those strategies for maximum impact (4-6).

Emergency Department Visits for Firearm Injuries Before and During the COVID-19 Pandemic - United States, January 2019-December 2022.

During the COVID-19 pandemic, the U.S. firearm homicide rate increased by nearly 35%, and the firearm suicide rate remained high during 2019-2020 (1). Provisional mortality data from the National Vital Statistics System indicate that rates continued to increase in 2021: the rates of firearm homicide and firearm suicide in 2021 were the highest recorded since 1993 and 1990, respectively (2). Firearm injuries treated in emergency departments (EDs), the primary setting for the immediate medical treatment of such injuries, gradually increased during 2018-2019 (3); however, more recent patterns of ED visits for firearm injuries, particularly during the COVID-19 pandemic, are unknown. Using data from the National Syndromic Surveillance Program (NSSP),* CDC examined changes in ED visits for initial firearm injury encounters during January 2019-December 2022, by year, patient sex, and age group. Increases in the overall weekly number of firearm injury ED visits were detected at certain periods during the COVID-19 pandemic. One such period during which there was a gradual increase was March 2020, which coincided with both the declaration of COVID-19 as a national emergency† and a pronounced decrease in the total number of ED visits. Another increase in firearm injury ED visits occurred in late May 2020, concurrent with a period marked by public outcry related to social injustice and structural racism (4), changes in state-level COVID-19-specific prevention strategies,§ decreased engagement in COVID-19 mitigation behaviors (5), and reported increases in some types of crime (4). Compared with 2019, the average number of weekly ED visits for firearm injury was 37% higher in 2020, 36% higher in 2021, and 20% higher in 2022. A comprehensive approach is needed to prevent and respond to firearm injuries in communities, including strategies that engage community and street outreach programs, implement hospital-based violence prevention programs, improve community physical environments, enhance secure storage of firearms, and strengthen social and economic supports.

Gun Carrying Among Youths, by Demographic Characteristics, Associated Violence Experiences, and Risk Behaviors - United States, 2017-2019.

Suicide and homicide are the second and third leading causes of death, respectively, among youths aged 14-17 years (1); nearly one half (46%) of youth suicides and most (93%) youth homicides result from firearm injuries (1). Understanding youth gun carrying and associated outcomes can guide prevention initiatives (2). This study used the updated measure of gun carrying in the 2017 and 2019 administrations of CDC's Youth Risk Behavior Survey* (YRBS) to describe the national prevalence of gun carrying for reasons other than hunting or sport among high school students aged <18 years and to examine the associations between gun carrying and experiencing violence, suicidal ideation or attempts, or substance use. Gun carrying during the previous 12 months was reported by one in 15 males and one in 50 females. Gun carrying was significantly more likely among youths with violence-related experiences (adjusted prevalence ratio [aPR] range = 1.5-10.1), suicidal ideation or attempts (aPR range = 1.8-3.5), or substance use (aPR range = 4.2-5.6). These results underscore the importance of comprehensive approaches to preventing youth violence and suicide, including strategies that focus on preventing youth substance use and gun carrying (3).

County-Level Social Vulnerability and Emergency Department Visits for Firearm Injuries - 10 U.S. Jurisdictions, January 1, 2018-December 31, 2021.

At least 100,000 persons in the United States experience a fatal or nonfatal firearm injury each year.* CDC examined rates of firearm injury emergency department (ED) visits by community social vulnerability using data from CDC's Firearm Injury Surveillance Through Emergency Rooms (FASTER) program.† ED visit data, shared with CDC's National Syndromic Surveillance Program (NSSP)§ during 2018-2021, were analyzed for 647 counties in 10 FASTER-funded jurisdictions.¶ County-level social vulnerability data were obtained from the 2018 Social Vulnerability Index (SVI).** Rates of ED visits for firearm injuries (number of firearm injury ED visits per 100,000 ED visits) were calculated across tertile levels of social vulnerability. Negative binomial regression models were used to estimate rate ratios (RRs) and associated 95% CIs comparing rates of ED visits across social vulnerability levels. During 2018-2021, compared with rates in counties with low overall social vulnerability, the firearm injury ED visit rate was 1.34 times as high in counties with medium social vulnerability and 1.80 times as high in counties with high social vulnerability. Similar patterns were observed for the SVI themes of socioeconomic status and housing type and transportation, but not for the themes of household composition and disability status or racial and ethnic minority status and language proficiency. More timely data†† on firearm injury ED visits by social vulnerability can help identify communities disproportionately experiencing elevated firearm injury rates. States and communities can use the best available evidence to implement comprehensive prevention strategies that address inequities in the social and structural conditions that contribute to risk for violence, including creating protective community environments, strengthening economic supports, and intervening to reduce harms and prevent future risk (e.g., with hospital-based violence intervention programs) (1,2).

Using the Centers for Disease Control and Prevention's National Syndromic Surveillance Program Data to Monitor Trends in US Emergency Department Visits for Firearm Injuries, 2018 to 2019.

STUDY OBJECTIVE: We describe trends in emergency department (ED) visits for initial firearm injury encounters in the United States. METHODS: Using data from the Centers for Disease Control and Prevention's National Syndromic Surveillance Program, we analyzed monthly and yearly trends in ED visit rates involving a firearm injury (calculated as the number of firearm injury-related ED visits divided by the total number of ED visits for each month and multiplied by 100,000) by sex-specific age group and US region from 2018 to 2019 and conducted Joinpoint regression to detect trend significance. RESULTS: Among approximately 215 million ED visits captured in the National Syndromic Surveillance Program from January 2018 to December 2019, 132,767 involved a firearm injury (61.6 per 100,000 ED visits). Among males, rates of firearm injury-related ED visits significantly increased for all age groups between 15 and 64 years during the study period. Among females, rates of firearm injury-related ED visits significantly increased for all age groups between 15 and 54 years during the study period. By region, rates significantly changed in the northeast, southeast, and southwest for males and females during the study period. CONCLUSION: These analyses highlight a novel data source for monitoring trends in ED visits for firearm injuries. With increased and effective use of state and local syndromic surveillance data, in addition to improvements to firearm injury syndrome definitions by intent, public health professionals could better detect unusual patterns of firearm injuries across the United States for improved prevention and tailored response efforts.

Firearm Homicides and Suicides in Major Metropolitan Areas - United States, 2015-2016 and 2018-2019.

Firearm homicides and suicides represent an ongoing public health concern in the United States. During 2018-2019, a total of 28,372 firearm homicides (including 3,612 [13%] among youths and young adults aged 10-19 years [youths]) and 48,372 firearm suicides (including 2,463 [5%] among youths) occurred among U.S. residents (1). This report is the fourth in a series* that provides statistics on firearm homicides and suicides in major metropolitan areas. As with earlier reports, this report provides a special focus on youth violence, including suicide, recognizing the magnitude of the problem and the importance of early prevention efforts. Firearm homicide and suicide rates were calculated for the 50 most populous U.S. metropolitan statistical areas (MSAs)† for the periods 2015-2016 and 2018-2019, separated by a transition year (2017), using mortality data from the National Vital Statistics System (NVSS) and population data from the U.S. Census Bureau. Following a period of decreased firearm homicide rates among persons of all ages after 2006-2007 in large metropolitan areas collectively and nationally, by 2015-2016 rates had returned to levels comparable to those observed a decade earlier and remained nearly unchanged as of 2018-2019. Firearm suicide rates among persons aged ≥10 years have continued to increase in large MSAs collectively as well as nationally. Although the youth firearm suicide rate remained much lower than the overall rate, the youth rate nationally also continued to increase, most notably outside of large MSAs. The findings in this report underscore a continued and urgent need for a comprehensive approach to prevention. This includes efforts to prevent firearm homicide and suicide in the first place and support individual persons and communities at increased risk, as well as lessening harms after firearm homicide and suicide have occurred.

Changes in prevalence of violence and risk factors for violence and HIV among children and young people in Kenya: a comparison of the 2010 and 2019 Kenya Violence Against Children and Youth Surveys.

BACKGROUND: Previous research has shown a high prevalence of violence among young people in Kenya. Violence is a known risk factor for HIV acquisition and these two public health issues could be viewed as a syndemic. In 2010, Kenya became the third country to implement the Violence Against Children and Youth Survey (VACS). The study found a high prevalence of violence in the country. Led by the Government of Kenya, stakeholders implemented several prevention and response strategies to reduce violence. In 2019, Kenya implemented a second VACS. This study examines the changes in violence and risk factors for violence and HIV between 2010 and 2019. METHODS: The 2010 and 2019 VACS used a similar sampling approach and measures. Both VACS were cross-sectional national household surveys of young people aged 13-24 years, designed to produce national estimates of physical, sexual, and emotional violence. Prevalence and changes in lifetime experiences of violence and risk factors for violence and HIV were estimated. The VACS uses a three-stage cluster sampling approach with random selection of enumeration areas as the first stage, households as the second stage, and an eligible participant from the selected household as the third stage. The VACS questionnaire contains sections on demographics, risk and protective factors, violence victimisation, violence perpetration, sexual behaviour, HIV testing and services, violence service knowledge and uptake, and health outcomes. For this study, the main outcome variables were violence victimisation, context of violence, and risk factors for violence. All analyses were done with the entire sample of 13-24-year-olds stratified by sex and survey year. FINDINGS: The prevalence of lifetime sexual, physical, and emotional violence significantly declined in 2019 compared with 2010, including unwanted sexual touching, for both females and males. Experience of pressured and forced sex among females also decreased between the surveys. Additionally, significantly more females sought and received services for sexual violence and significantly more males knew of a place to seek help in 2019 than in 2010. The prevalence of several risk factors for violence and HIV also declined, including infrequent condom use, endorsement of inequitable gender norms, endorsement of norms justifying wife beating, and never testing for HIV. INTERPRETATION: Kenya observed significant declines in the prevalence of lifetime violence and some risk factors for violence and HIV, and improvements in some service seeking indicators between 2010 and 2019. Continued prioritisation of preventing and responding to violence in Kenya could contribute to further reductions in violence and its negative outcomes. Other countries in the region that have made substantial investments and implemented similar violence prevention programmes could use repeat VACS data to monitor violence and related outcomes over time. FUNDING: None.

Examining differences between mass, multiple, and single-victim homicides to inform prevention: findings from the National Violent Death Reporting System.

BACKGROUND: Multi-victim homicides are a persistent public health problem confronting the United States. Previous research shows that homicide rates in the U.S. are approximately seven times higher than those of other high-income countries, driven by firearm homicide rates that are 25 times higher; 31% of public mass shootings in the world also occur in the U.S.. The purpose of this analysis is to examine the characteristics of mass, multiple, and single homicides to help identify prevention points that may lead to a reduction in different types of homicides. METHODS: We used all available years (2003-2017) and U.S. states/jurisdictions (35 states, the District of Columbia, and Puerto Rico) included in CDC's National Violent Death Reporting System (NVDRS), a public health surveillance system which combines death certificate, coroner/medical examiner, and law enforcement reports into victim- and incident-level data on violent deaths. NVDRS includes up to 600 standard variables per incident; further information on types of mental illness among suspected perpetrators and incident resolution was qualitatively coded from case narratives. Data regarding number of persons nonfatally shot within incidents were cross-validated when possible with several other resources, including government reports and the Gun Violence Archive. Mass homicides (4+ victims), multiple homicides (2-3 victims) and single homicides were analyzed to assess group differences using Chi-square tests with Bonferroni-corrected post-hoc comparisons. RESULTS: Mass homicides more often had female, child, and non-Hispanic white victims than other homicide types. Compared with victims of other homicide types, victims of mass homicides were more often killed by strangers or someone else they did not know well, or by family members. More than a third were related to intimate partner violence. Approximately one-third of mass homicide perpetrators had suicidal thoughts/behaviors noted in the time leading up to the incident. Multi-victim homicides were more often perpetrated with semi-automatic firearms than single homicides. When accounting for nonfatally shot victims, over 4 times as many incidents could have resulted in mass homicide. CONCLUSIONS: These findings underscore the important interconnections among multiple forms of violence. Primary prevention strategies addressing shared risk and protective factors are key to reducing these incidents.

A descriptive exploration of the geographic and sociodemographic concentration of firearm homicide in the United States, 2004-2018.

This study examined the population-based incidence of firearm homicide in the United States to identify geographic concentrations and to determine whether such concentrations have changed over time. It further examined the simultaneous associations of urbanization, poverty, and ethnicity/race with firearm homicide incidence. Using county-level data from the National Vital Statistics System and the U.S. Census Bureau for the years 2004-2018, the findings show geographic patterns not commonly recognized, including several lengthy and continuous corridors with a high incidence of firearm homicide, traversing both metro and non-metro areas. While the data clearly show a strongly disproportionate concentration of firearm homicide incidence in a subset of the population defined by geography, they do not suggest increasing concentration over time. The study findings also generally indicate increasing firearm homicide incidence with increasing levels of surrounding poverty, a phenomenon observed for both metro and non-metro areas.

Vital Signs: Prevalence of Multiple Forms of Violence and Increased Health Risk Behaviors and Conditions Among Youths - United States, 2019.

INTRODUCTION: Experiencing violence, especially multiple types of violence, can have a negative impact on youths' development. These experiences increase the risk for future violence and other health problems associated with the leading causes of morbidity and mortality among adolescents and adults. METHODS: Data from the 2019 national Youth Risk Behavior Survey were used to determine the prevalence of high school students' self-reported experiences with physical fighting, being threatened with a weapon, physical dating violence, sexual violence, and bullying. Logistic regression models adjusting for sex, grade, and race/ethnicity were used to test the strength of associations between experiencing multiple forms of violence and 16 self-reported health risk behaviors and conditions. RESULTS: Approximately one half of students (44.3%) experienced at least one type of violence; more than one in seven (15.6%) experienced two or more types during the preceding 12 months. Experiencing multiple types of violence was significantly more prevalent among females than among males and among students identifying as gay, lesbian, or bisexual or not sure of their sexual identity than among heterosexual students. Experiencing violence was significantly associated with higher prevalence of all examined health risks and conditions. Relative to youths with no violence experiences, adjusted health risk and condition prevalence estimates were up to seven times higher among those experiencing two types of violence and up to 21 times higher among those experiencing three or more types of violence. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Many youths experience multiple types of violence, with potentially lifelong health impacts. Violence is preventable using proven approaches that address individual, family, and environmental risks. Prioritizing violence prevention is strategic to promoting adolescent and adult health.

Getting Ahead of the Curve to Prevent Elder Mistreatment in the United States.

Elder mistreatment is an important public health problem that can be prevented. By investing in upstream prevention and taking a multigenerational approach, the U.S. can help create communities where older adults are safe, thriving, and living out the remainder of their lives free from abuse and exploitation. The need to do so has never been more pressing as the U.S. is on the precipice of historic population changes that could place a substantial burden on families, communities, and systems of care and protection for older adults. This article describes these changes and how public health efforts can make a difference.

Firearm Homicides and Suicides in Major Metropolitan Areas - United States, 2012-2013 and 2015-2016.

Firearm homicides and suicides represent a continuing public health concern in the United States. During 2015-2016, a total of 27,394 firearm homicides (including 3,224 [12%] among persons aged 10-19 years) and 44,955 firearm suicides (including 2,118 [5%] among persons aged 10-19 years) occurred among U.S. residents (1). This report updates an earlier report (2) that provided statistics on firearm homicides and suicides in major metropolitan areas during 2006-2007 and 2009-2010, and places continued emphasis on youths, in recognition of the importance of early prevention efforts. Firearm homicide and suicide rates were determined for the 50 most populous U.S. metropolitan statistical areas (MSAs)* during 2012-2013 and 2015-2016 using mortality data from the National Vital Statistics System (NVSS) and population data from the U.S. Census Bureau. In contrast to the earlier report, which indicated that firearm homicide rates among persons of all ages had been declining both nationally and in large MSAs overall, current findings show that rates have returned to levels comparable to those observed during 2006-2007. Consistent with the earlier report, these findings show that firearm suicide rates among persons aged ≥10 years have continued to increase, both nationally and in large MSAs overall. Although firearm suicide rates among youths remain notably lower than those among persons of all ages, youth rates have also increased both nationally and in large MSAs collectively. These findings can inform ongoing development and monitoring of strategies directed at reducing firearm-related violence.

Childhood Firearm Injuries in the United States.

OBJECTIVES: Examine fatal and nonfatal firearm injuries among children aged 0 to 17 in the United States, including intent, demographic characteristics, trends, state-level patterns, and circumstances. METHODS: Fatal injuries were examined by using data from the National Vital Statistics System and nonfatal injuries by using data from the National Electronic Injury Surveillance System. Trends from 2002 to 2014 were tested using joinpoint regression analyses. Incident characteristics and circumstances were examined by using data from the National Violent Death Reporting System. RESULTS: Nearly 1300 children die and 5790 are treated for gunshot wounds each year. Boys, older children, and minorities are disproportionately affected. Although unintentional firearm deaths among children declined from 2002 to 2014 and firearm homicides declined from 2007 to 2014, firearm suicides decreased between 2002 and 2007 and then showed a significant upward trend from 2007 to 2014. Rates of firearm homicide among children are higher in many Southern states and parts of the Midwest relative to other parts of the country. Firearm suicides are more dispersed across the United States with some of the highest rates occurring in Western states. Firearm homicides of younger children often occurred in multivictim events and involved intimate partner or family conflict; older children more often died in the context of crime and violence. Firearm suicides were often precipitated by situational and relationship problems. The shooter playing with a gun was the most common circumstance surrounding unintentional firearm deaths of both younger and older children. CONCLUSIONS: Firearm injuries are an important public health problem, contributing substantially to premature death and disability of children. Understanding their nature and impact is a first step toward prevention.

Development of the SaFETy Score: A Clinical Screening Tool for Predicting Future Firearm Violence Risk.

BACKGROUND: Interpersonal firearm violence among youth is a substantial public health problem, and emergency department (ED) physicians require a clinical screening tool to identify high-risk youth. OBJECTIVE: To derive a clinically feasible risk index for firearm violence. DESIGN: 24-month prospective cohort study. SETTING: Urban, level 1 ED. PARTICIPANTS: Substance-using youths, aged 14 to 24 years, seeking ED care for an assault-related injury and a proportionately sampled group of non-assault-injured youth enrolled from September 2009 through December 2011. MEASUREMENTS: Firearm violence (victimization/perpetration) and validated questionnaire items. RESULTS: A total of 599 youths were enrolled, and presence/absence of future firearm violence during follow-up could be ascertained in 483 (52.2% were positive). The sample was randomly split into training (75%) and post-score-construction validation (25%) sets. Using elastic-net penalized logistic regression, 118 baseline predictors were jointly analyzed; the most predictive variables fell predominantly into 4 domains: violence victimization, community exposure, peer influences, and fighting. By selection of 1 item from each domain, the 10-point SaFETy (Serious fighting, Friend weapon carrying, community Environment, and firearm Threats) score was derived. SaFETy was associated with firearm violence in the validation set (odds ratio [OR], 1.47 [95% CI, 1.23 to 1.79]); this association remained (OR, 1.44 [CI, 1.20 to 1.76]) after adjustment for reason for ED visit. In 5 risk strata observed in the training data, firearm violence rates in the validation set were 18.2% (2 of 11), 40.0% (18 of 45), 55.8% (24 of 43), 81.3% (13 of 16), and 100.0% (6 of 6), respectively. LIMITATIONS: The study was conducted in a single ED and involved substance-using youths. SaFETy was not externally validated. CONCLUSION: The SaFETy score is a 4-item score based on clinically feasible questionnaire items and is associated with firearm violence. Although broader validation is required, SaFETy shows potential to guide resource allocation for prevention of firearm violence. PRIMARY FUNDING SOURCE: National Institute on Drug Abuse R01024646.

Sexual Violence Against Female and Male Children in the United Republic of Tanzania.

During a household survey in Tanzania, a nationally representative sample of females and males aged 13-24 years reported any experiences of sexual violence that occurred before the age of 18 years. The authors explore the prevalence, circumstances, and health outcomes associated with childhood sexual violence. The results suggest that violence against children in Tanzania is pervasive, with roughly three in 10 females and one in eight males experiencing some form of childhood sexual violence, and its health consequences are severe. Results are being used by the Tanzanian government to implement a National Plan of Action.

Global Status Report on Violence Prevention 2014.

INTRODUCTION: Interpersonal violence affects millions of people worldwide, often has lifelong consequences, and is gaining recognition as an important global public health problem. There has been no assessment of measures countries are taking to address it. This report aims to assess such measures and provide a baseline against which to track future progress. METHODS: In each country, with help from a government-appointed National Data Coordinator, representatives from six to ten sectors completed a questionnaire before convening in a consensus meeting to decide on final country data; 133 of 194 (69%) WHO Member States participated. The questionnaire covered data, plans, prevention measures, and victim services. Data were collected between November 2012 and June 2014, and analyzed between June and October 2014. Global and country-level homicides for 2000-2012 were also calculated for all 194 Members. RESULTS: Worldwide, 475,000 people were homicide victims in 2012 and homicide rates declined by 16% from 2000 to 2012. Data on fatal and, in particular, non-fatal forms of violence are lacking in many countries. Each of the 18 types of surveyed prevention programs was reported to be implemented in a third of the 133 participating countries; each law was reported to exist in 80% of countries, but fully enforced in just 57%; and each victim service was reported to be in place in just more than half of the countries. CONCLUSIONS: Although many countries have begun to tackle violence, serious gaps remain, and public health researchers have a critical role to play in addressing them.

HIV and Childhood Sexual Violence: Implications for Sexual Risk Behaviors and HIV Testing in Tanzania.

Prior research has established an association between sexual violence and HIV. Exposure to sexual violence during childhood can profoundly impact brain architecture and stress regulatory response. As a result, individuals who have experienced such trauma may engage in sexual risk-taking behavior and could benefit from targeted interventions. In 2009, nationally representative data were collected on violence against children in Tanzania from 13-24 year old respondents (n=3,739). Analyses show that females aged 19-24 (n=579) who experienced childhood sexual violence, were more likely to report no/infrequent condom use in the past 12 months (AOR=3.0, CI [1.5, 6.1], p=0.0017) and multiple sex partners in the past 12 months (AOR=2.3, CI [1.0, 5.1], p=0.0491), but no more likely to know where to get HIV testing or to have ever been tested. Victims of childhood sexual violence could benefit from targeted interventions to mitigate impacts of violence and prevent HIV.

Violence in the United States: Status, Challenges, and Opportunities.

IMPORTANCE: Interpersonal violence, which includes child abuse and neglect, youth violence, intimate partner violence, sexual violence, and elder abuse, affects millions of US residents each year. However, surveillance systems, programs, and policies to address violence often lack broad, cross-sector collaboration, and there is limited awareness of effective strategies to prevent violence. OBJECTIVES: To describe the burden of interpersonal violence in the United States, explore challenges to violence prevention efforts and to identify prevention opportunities. DATA SOURCES: We reviewed data from health and law enforcement surveillance systems including the National Vital Statistics System, the Federal Bureau of Investigation's Uniform Crime Reports, the US Justice Department's National Crime Victimization Survey, the National Survey of Children's Exposure to Violence, the National Child Abuse and Neglect Data System, the National Intimate Partner and Sexual Violence Survey, the Youth Risk Behavior Surveillance System, and the National Electronic Injury Surveillance System-All Injury Program. RESULTS: Homicide rates have decreased from a peak of 10.7 per 100,000 persons in 1980 to 5.1 per 100,000 in 2013. Aggravated assault rates have decreased from a peak of 442 per 100,000 in 1992 to 242 per 100,000 in 2012. Nevertheless, annually, there are more than 16,000 homicides and 1.6 million nonfatal assault injuries requiring treatment in emergency departments. More than 12 million adults experience intimate partner violence annually and more than 10 million children younger than 18 years experience some form of maltreatment from a caregiver, ranging from neglect to sexual abuse, but only a small percentage of these violent incidents are reported to law enforcement, health care clinicians, or child protective agencies. Moreover, exposure to violence increases vulnerability to a broad range of mental and physical health problems over the life course; for example, meta-analyses indicate that exposure to physical abuse in childhood is associated with a 54% increased odds of depressive disorder, a 78% increased odds of sexually transmitted illness or risky sexual behavior, and a 32% increased odds of obesity. Rates of violence vary by age, geographic location, sex, and race/ethnicity, and significant disparities exist. Homicide is the leading cause of death for non-Hispanic blacks from age 1 through 44 years, whereas it is the fifth most common cause of death among non-Hispanic whites in this age range. Additionally, efforts to understand, prevent, and respond to interpersonal violence have often neglected the degree to which many forms of violence are interconnected at the individual level, across relationships and communities, and even intergenerationally. The most effective violence prevention strategies include parent and family-focused programs, early childhood education, school-based programs, therapeutic or counseling interventions, and public policy. For example, a systematic review of early childhood home visitation programs found a 38.9% reduction in episodes of child maltreatment in intervention participants compared with control participants. CONCLUSIONS AND RELEVANCE: Progress has been made in reducing US rates of interpersonal violence even though a significant burden remains. Multiple strategies exist to improve violence prevention efforts, and health care providers are an important part of this solution.